Step 1 of 2 50% URLThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formhidden claimant id*This field is hidden when viewing the formhidden last name* CLAIM FORM Ahlers, et al. v. Allina Health System United States District Court for the District of Minnesota Case No. 0:24-cv-03674-SRN-ECW GENERAL CLAIM FORM INFORMATION The Settlement Class consists of those individuals who were portal users, non-portal bill pay users, and non-portal scheduling users between SEPTEMBER 16, 2018, through MAY 11, 2026, (“Group 1 Settlement Class Members”) and individuals who were non-portal, non-bill pay, and non-scheduling patients between SEPTEMBER 16, 2018, through MAY 11, 2026, (“Group 2 Settlement Class Members”). Your designation as a Group 1 or Group 2 Class Member does not affect the manner in which you submit a Claim Form. If you wish to submit a Claim Form for a pro rata payment, please verify or update your address, select the method of payment you prefer, and agree to the certification statement on the next pages. Claim Forms must be filed on or before SEPTEMBER 8, 2026. If you would like to submit your Claim Form by mail, click HERE to download and print a copy, then complete and mail it. Please keep a copy of your completed Claim Form for your records. I. SETTLEMENT CLASS MEMBER INFORMATIONNAME:* First Last MAILING ADDRESS:* Mailing Address (Street Address including apartment number, suite, floor, or other pertinent detail, or PO Box) City State / Province / Region Zip Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address:* Telephone Number with area code:*Notice ID:*This is the 8-digit alpha-numeric identification code included in the Notice sent by mail or email Payment SelectionPlease select one payment method for receipt of any Settlement payment to which you are determined eligible: This field is hidden when viewing the formPayment Token*Payment Method:*II. CERTIFICATION OF CLAIM I declare under penalty of perjury under the laws of the United States and the state where I reside that this Claim is true and correct to the best of my recollection, and that this form was executed on the date set forth below. I further attest that I accessed Allina Health System’s websites or webpages as a portal user, non-portal bill pay user, or non-portal scheduling user between SEPTEMBER 16, 2018, and MAY 11, 2026, or as a non-portal, non-bill pay, or non-scheduling patient between SEPTEMBER 16, 2018, and MAY 11, 2026. I understand that this information is subject to verification, that I may be asked by the Settlement Administrator to provide supplemental information to validate my claim, and that by completing and submitting this form by mail, my payment, should I be deemed eligible to receive one, will be a check sent to me by mail. Printed Signature:*Date:* MM slash DD slash YYYY ClaimFormNo
